Four Seasons Healthcare: Medication Safety Failures - CA
What inspectors found when they came was that the policy and the practice had come apart.
Federal inspectors cited Four Seasons Healthcare & Wellness Center, LP in North Hollywood during a complaint inspection on May 26, 2026, for failures in how medications were administered and how pharmacy deliveries were handled. The violations affected a small number of residents and were classified as causing minimal harm or the potential for actual harm, but the breakdown inspectors documented ran through nearly every step of the medication process the facility had committed to on paper.
The facility's own Medication Administration policy set a clear window: medications must reach residents within one hour before or one hour after their scheduled time. That window exists for a reason. Some medications are tied to meals. Some are timed around other drugs. Some lose their clinical purpose if given too early or too late. The policy acknowledged that a specific clinical reason could justify a tighter schedule, which means the default assumption was that timing mattered enough to write a rule around it.
Inspectors found that window wasn't being reliably honored.
The pharmacy delivery policy was, if anything, more detailed. It laid out five distinct steps a licensed nurse was supposed to follow every time medications arrived at the facility. Receive the delivery and document it. Verify what came in against the order. Report any problems to the pharmacy and the supervisor right away. Get the medications into secure storage immediately. Make sure everything is incorporated into each resident's individual supply before the next medication pass goes out.
Five steps. Each one a checkpoint. Together they form a chain meant to ensure that what a doctor ordered is what a resident actually receives, in the right amount, at the right time, without gaps or substitutions slipping through unnoticed.
Inspectors found that chain wasn't holding.
The inspection report does not describe a single dramatic incident, a resident harmed in a way that made headlines, a medication error that sent someone to the hospital. What it describes is something quieter and, in some ways, harder to fix: a systemic looseness in how the facility handled the basic logistics of getting medications from a pharmacy to a resident's body on schedule and with proper verification at every step.
That kind of looseness is how errors accumulate. A delivery arrives and isn't fully checked against the order. A discrepancy goes unreported because no one caught it. A medication sits outside secure storage longer than it should. The next medication pass goes out before a new supply has been properly incorporated into a resident's allocation. None of those individual failures necessarily causes immediate harm. Together, over time, they create conditions where harm becomes more likely and harder to trace when it does occur.
Four Seasons Healthcare & Wellness Center is a licensed nursing facility operating in North Hollywood. The inspection was triggered by a complaint, meaning someone, a resident, a family member, a staff member, believed something was wrong and reported it. The inspection confirmed failures across both medication administration and the pharmacy receiving process.
The facility's own policy review date was April 22, 2026. Thirty-four days later, inspectors arrived and found the facility wasn't following what it had just reviewed and reaffirmed. The policies were current. The practice wasn't.
For the residents whose medications weren't arriving on schedule, or whose pharmacy deliveries weren't being properly verified before the next pass, the gap between what the policy promised and what was actually happening wasn't abstract.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Healthcare & Wellness Center, Lp from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 20, 2026 · Our methodology
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on May 26, 2026.
What inspectors found when they came was that the policy and the practice had come apart.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.